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urease print or type. (rorm aeslgneo ror use on eine (iz-p¢cn) rypewmec) rorm Approvea. uMD rvu. Luau -woe UNIFORM HAZARDOUS ` r1. Generator ID Number a rgency Response Phone f7L 0003156 .. 1 • i .. 5'x `7 4. Manifest Trackin Number JJ K WASTE MANIFEST 5. 9wer to Pgan 11 aiill Addres Generator's Site Address ('d different than mailing address) 7 Z012 CA K 2 06 Generators Phone: ;A14 4Ai-, — V 0 .r f 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8.O�ysjgnafeMl(t Tametnd� SE'de Address U.S. EPA ID Number Ytmn, A% a5365 Facility's Phone: ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No Type HM and Packing Group (if any)) Quantity Wt.Nol. Z UJI 2. d tw s a kx • a i; 3. 4. 14.fTdjn1ndlio InggtV and ditiq . 'nfo '.tl)— -Ls1 9^ 5It i" . 3 i4 <k 'A... 'a' i": :#'i:h'�:._i". :.:;,_ 7 �_ >.t,tt .il`i:.;3.E1$1�,. PER an ,�.ni.S .. f 'd'id k t.38�:>16S„-_h . r? ..'r a"r i1'r3 •^a4 'lil 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labelediplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (f I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's/Offeror's Pdnted/Typed Name Signature Month Day Year J a— 16, Intemational Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: z Transporter signature (for exports only): Date leaving U.S.: 17. TransporterAcknowledgment of Receipt of Materials Transporter 1 Pri to yped Name Signatures', �` ` _ ! Month Day Year QTransporter 2 Printed/Typed Name Signature ( Month Day Year H 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residuej ❑ j ❑ Partial Re ection Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) ? U.S. EPA ID Number J V Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certificafion of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL. COPY